Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Measurement and Monitoring, Extracorporeal Assistance and Performance, and Extracorporeal Therapies

By Ann Barta, MSA, RHIA, CDIP

Editor’s note: This is the second in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.

In this article, the Journal of AHIMA continues its three part Coding Notes series focusing on the nine Medical and Surgical-related sections of ICD-10-PCS. This article will take a more in-depth look at three of these nine sections:

• Measurement and Monitoring
• Extracorporeal Assistance and Performance
• Extracorporeal Therapies

Measurement and Monitoring: Section Value 4

The Measurement and Monitoring section of ICD-10-PCS only has two root operations: Measurement and Monitoring. Measurement is the first root operation and is used when the procedure determines the level of a physiological or physical function at a point in time. Monitoring is the second root operation and is used when the procedure determines the level of a physiological or physical function repetitively over a period of time. The table "Root Operations by Medical and Surgical-Related Section" below outlines the character values for these two root operations as well as their respective definitions.

The seven characters in the Measurement and Monitoring section are shown in Figure 1.

Comparing ICD-9-CM and ICD-10-PCS: Measurement and Monitoring

The following is an example of how ICD-9-CM and ICD-10-PCS compare when assigning codes in the Measurement and Monitoring section.

Case Scenario

The patient was admitted with unstable angina. Diagnostic testing ruled out myocardial infarctions and the decision was made for the patient to undergo a left heart catheterization with left ventriculogram and coronary angiography of both left and right coronary arteries. The patient was taken to the cardiac catheterization laboratory. The right femoral artery was entered with an 18-guage needle and a J guide wire was then introduced into the descending aorta. A #6 French left coronary artery catheter was introduced over the guide wire. Selective injections using low osmolar dye were made in the left and right coronary arteries. The coronary artery catheter was exchanged for #6 French pigtail catheter and left heart catheterization was performed at rest with pressures being measured. A left ventriculogram was performed using low osmolar dye.

In ICD-9-CM, the Alphabetic Index main term entry for the left heart catheterization is Catheterization, subterms, Heart, left which identifies code 37.22. The main term entry for the left ventriculogram is Ventriculogram, subterms Cardiac, left ventricle which identifies code 88.53. Finally, the main term entry for the coronary angiography is Arteriography, subterm Coronary identifying the code 88.57.

ICD-9-CM differentiates between a left heart catheterization, 37.22, right heart catheterization, 37.21 and combined heart catheterization, 37.23. Although not common, if a heart catheterization is performed with an open approach, a code from category 37 would also be assigned since ICD-9-CM does not provide separate codes based on the approach.

In ICD-10-PCS, the root operation for a heart catheterization is Measurement with the code for a left heart catheterization being 4A023N7. During a cardiac catheterization, measurements of pressures within the heart chambers are taken with the sixth character of the code, sampling and pressure, capturing this function. The seventh character identifies if the procedure is performed on the left, right, or is bilateral. Unlike ICD-9-CM, ICD-10-PCS differentiates the various approaches to performing this procedure with the fifth character capturing the approach.

Extracorporeal Assistance and Performance: Section Value 5

The Extracorporeal Assistance and Performance section, for procedures where equipment outside the body is used to assist/perform physiological function, has three unique root operations: Assistance, Performance, and Restoration. The table "Root Operations by Medical and Surgical-Related Section" below outlines the character values and respective definitions for these three root operations.

The seven characters in the Extracorporeal Assistance and Performance section are shown in Figure 2.

Comparing ICD-9-CM and ICD-10-PCS: Extracorporeal Assistance and Performance

The following are two examples of how ICD-9-CM and ICD-10-PCS compare when assigning codes in the Extracorporeal Assistance and Performance section.

Case Scenario #1

The patient for this case scenario is admitted with acute respiratory failure. The patient also has stage IV lung carcinoma. The patient required intubation and mechanical ventilation for 54 consecutive hours.

In ICD-9-CM, the insertion of the endotracheal tube with subsequent mechanical ventilation requires two codes. In the ICD-9-CM Alphabetic Index the main term for the insertion of the endotracheal tube is Insertion, subterms Tube, endotracheal which identifies code 96.04. The main term for the continuous mechanical ventilation is Ventilation, subterms Mechanical, other continuous invasive, for less than 96 consecutive hours resulting in code 96.71. ICD-9-CM provides three unique codes for mechanical ventilated based on the number of consecutive hours: 96.70 for unspecified duration, 96.71 for less than 96 consecutive hours, and 96.72 for 96 consecutive hours or more.

In ICD-10-PCS, the insertion of an endotracheal tube with subsequent mechanical ventilation requires only one procedure code. Per the Centers for Medicare and Medicaid Services’ ICD-10-PCS Reference Manual, the insertion of an endotracheal tube associated with the mechanical ventilation procedure is considered a component of the equipment used in performing the procedure and is not coded separately. The mechanical ventilation is coded to the root operation Performance with the code for the procedure being 5A1945Z. The range of consecutive hours for mechanical ventilation in ICD-10-PCS is different than ICD-9-CM. The ranges are less than 24 consecutive hours, 24 to 96 consecutive hours, and greater than 96 consecutive hours.

Case Scenario #2

A patient with severe arteriosclerotic heart disease of the native arteries was admitted for coronary artery bypass graft (CABG) times three, open approach, with cardiopulmonary bypass. During the operative procedure all three coronary arteries were bypassed via the aortocoronary bypass technique utilizing saphenous vein grafts which had been harvested previously.

In ICD-9-CM, the Alphabetic Index main term entry is Bypass, subterms Aortocoronary, three coronary vessels which identifies code 36.13. ICD-9-CM does not differentiate the type of graft material; therefore, 36.13 is assigned for autologous venous tissue, autologous arterial tissue, synthetic substitute material and nonautologous tissue substitute material. The cardiopulmonary bypass codes to 39.61, Extracorporeal circulation auxiliary to open heart surgery.

In ICD-10-PCS, the root operation for the CABG is Bypass from the Medical and Surgical section of ICD-10-PCS with code 021209W being assigned. Unlike ICD-9-CM, ICD-10-PCS does differentiate the type of graft material in the device character of the code. The root operation for the cardiopulmonary bypass is Performance from the Extracorporeal Assistance and Performance section of ICD-10-PCS with code 5A1221Z being assigned.

Extracorporeal Therapies: Section Value 6

See the table "Root Operations by Medical and Surgical-Related Section" below for the 10 Extracorporeal Therapies section root operations and their definitions.

The seven characters in the Extracorporeal Therapies section are shown in Figure 3.

Comparing ICD-9-CM and ICD-10-PCS: Extracorporeal Therapies

The following is an example of how ICD-9-CM and ICD-10-PCS compare when assigning codes in the Extracorporeal Therapies section.

Case Scenario

A patient receives a single treatment of plasmapheresis for myasthenia gravis. This procedure consists of removal of the patient’s blood, separation of blood cells from plasma, and then returning the blood cells to the patient’s circulation, diluted with fresh plasma or a substitute. This procedure is also often referred to as therapeutic plasma exchange.

In ICD-9-CM, the Alphabetic Index main term entry is Plasmapheresis, therapeutic which identifies code 99.71. In ICD-10-PCS, the root operation for this procedure is Pheresis with the code 6A550Z3 being assigned for this procedure. The fifth character of this code captures whether the treatment is single (0) or multiple (1). The seventh character captures the blood product that is being extracorporeally separated as follows: erythrocytes (0), leukocytes (1), platelets (2), plasma (3), stem cells, cord blood (4), or stem cells, hematopoietic (5).

References

Barta, Ann and Ann Zeisset. Root Operations: Key to Procedure Coding in ICD-10-PCS. Chicago: AHIMA Press, 2010.

Centers for Medicare and Medicaid Services. “2014 Code Tables and Index.” 2013. http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

Centers for Medicare and Medicaid Services. “ICD-10-PCS Official Guidelines for Coding and Reporting 2014.” 2013. http://www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS-2014-guidelines.pdf.

Centers for Medicare and Medicaid Services. “2014 ICD-10-PCS Reference Manual.” 2013. http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

Ann Barta (ann.barta@uasisolutions.com) is a senior HIM consultant for UASI.